This week in Medicare—12/20/2023
Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting & Reporting Data for the Private Payor Rate-Based Payment System
On December 4, CMS revised Special Edition MLN Matters 19006 to note that for CDLTs that aren’t ADLTs, the data reporting period is delayed and resumes starting January 1, 2025 – March 31, 2025. CMS also extended the 0% limit on laboratory payment reductions to the end of CY 2024 and the 15% limit on payment reductions per year to CY 2025 – 2027. The initial article was released in 2019, and this reporting period has been delayed multiple times since then.
Activation of Validation Edits for Providers with Multiple Service Locations
On December 7, CMS revised Special Edition MLN Matters 19007 regarding information on the activation of validation edits for providers with multiple service locations. CMS added information on how to verify and update service locations for Medicare enrollment and what claim modifier to use. It substantially revised information on pages 2-4 regarding how it defines certain practice locations and how to fill out information in PECOS and on the claim line level.
Medicare Part B Inflation Rebate Guidance: Use of the 340B Modifier
On December 11, CMS revised an MLN Fact Sheet regarding the use of the 340B modifiers to identify drugs acquired through the 340B program. CMS added information on what modifiers different categories of 340B covered entities should use in CY 2024 and what providers will need to report starting January 1, 2025.
MLN Booklet: Global Surgery
On December 11, CMS revised an MLN Booklet about Medicare’s global surgery package requirements. CMS changed information on page 7 to note that providers should report modifier -FT for critical care visits that are unrelated to the surgical procedure and performed post-operatively.
Livanta Review: Higher-Weighted DRG (HWDRG) Validation – Appealing Livanta’s Determinations
On December 11, Livanta published the October 2023 edition of the Livanta Claims Review Advisor. This edition provides guidance to hospitals on how best to respond to potential or final determination letters from Livanta. It addresses the different types of HWDRG review determinations and what information hospitals should include for coding and medical necessity decisions that may support approvals.
The Consistently Low Percentage of Medicare Enrollees Receiving Medication to Treat Their Opioid Use Disorder Remains a Concern
On December 11, the OIG published a Report on Medicare beneficiaries’ access to life-saving treatment for opioid use disorder and the opioid overdose-reversal drug naloxone. The report is the latest installment in a series of annual reviews conducted by the OIG since 2017 to monitor indicators of the opioid epidemic in Medicare.
The OIG found that at least 51,864 Medicare beneficiaries received medical care after experiencing an opioid overdose in 2022. Although treating opioid use disorder with medications has been shown to decrease illicit opioid use and overdose deaths, the OIG found that only 18.4% of the 1.1 million enrollees with opioid use disorder received medication to treat their condition in 2022. Additionally, the OIG found notable disparities by age, race, ethnicity, income, and location in those receiving medication. However, the OIG also determined that the number of enrollees who received naloxone prescriptions in 2022 increased substantially to an all-time high of 607,794, up 36% from 2021.
To prevent further barriers, the OIG recommends that CMS educate enrollees and providers about options for access to overdose-reversal medications, as most will no longer be covered by Part D. The OIG also encouraged CMS to continue its efforts to implement recommendations in previous reports on this issue, such as informing providers about the use of buprenorphine.
CY 2024 Home Infusion Therapy (HIT) Payment Rates and Instructions for Retrieving the January 2024 HIT Services Payment Rates Through the CMS Mainframe Telecommunications System
On December 13, CMS published Medicare Claims Processing Transmittal 12406, which rescinds and replaces Transmittal 12264, dated November 6, to update the CR to reflect changes authorized by Section 501 of the Further Continuing Appropriations and Other Extensions Act, 2024, by revising the policy section and the HIT rates attachment as well as BR 13387.2. The CY 2024 geographic adjustment factors have been revised to reflect the extension of the work GPCI floor through January 19, 2024, as authorized by Section 501 of the Further Continuing Appropriations and Other Extensions Act, 2024.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Medicare Generally Paid Acute-Care Hospitals for Inpatient Stays for Medicare Enrollees Diagnosed With COVID-19 in Accordance with Federal Requirements
On December 13, the OIG published a Report regarding appropriate Medicare payment to acute care hospitals for COVID-19 inpatient stays. The report was created to analyze whether these claims met coverage, medical necessity, and coding requirements.
The OIG found that the overwhelming majority of the 149 sampled claims for inpatient stays for enrollees diagnosed with COVID-19 complied with federal requirements. Only three claims did not comply with the requirements, resulting in $18,911 in improper Medicare payments. The OIG did not include any recommendations because the improper payments identified in the report were primarily caused by clerical errors.
National Health Expenditures: 2022 Highlights
On December 13, CMS published a Fact Sheet regarding 2022 national health expenditures. The agency reported that U.S. healthcare spending grew 4.1% in 2022 to reach $4.5 trillion, which is a far slower increase than the 10.6% jump reported in 2020 but a faster rate than the 3.2% reported in 2021. The fact sheet also details healthcare spending by type of service or product, source of funds, and type of sponsor.
Direct Mailing Notification to Hospice Providers Regarding the Value-Based Insurance Design (VBID) Model, Hospice Benefit Component, Participating Medicare Advantage Organizations
On December 13, CMS published One-Time Notification Transmittal 12405 regarding a direct mailing that MACs have been instructed to send to hospice providers about the VBID model and hospice benefit component. It also provides education on participation and billing for Medicare Advantage enrollees receiving services in affected areas. The transmittal includes a copy of the direct mailing that the MACs will send out.
Effective date: January 16, 2024
Implementation date: January 16, 2024
Updating CY 2024 Medicare Diabetes Prevention Program (MDPP) Payment Rates
On December 13, CMS published One-Time Notification Transmittal 12410 regarding instructions for the MACs on how to update the systems with the updated MDPP expanded model payment rates for CY 2024. This information was published in the 2024 Physician Fee Schedule final rule.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Revised Guidance for Medicare Prescription Drug Inflation Rebate Program
On December 14, CMS published a Press Release to announce revised guidance on calculating rebates and invoicing manufacturers under the Medicare Prescription Drug Inflation Rebate Program. The agency published separate memorandums for Medicare Part B and Part D with specific guidance.
CMS revised the original program guidance to provide clarification, improve understanding of operational processes, and foster an effective inflation rebate program. The revised guidance details drug eligibility, exclusions, rebate payment calculation, and enforcement. CMS also included guardrails in the guidance to minimize incentives for drug companies to remain on a shortage list, delay resolution of severe supply chain disruptions, or put generic drugs at risk of shortage in order to avoid paying an inflation rebate. Along with the revised guidance, the agency released the list of 48 prescription drugs for which Part B beneficiary coinsurances may be lower between January 1 - March 31, 2024.
CMS also released a Fact Sheet on the revised guidance. It also published a Notice on the revised guidance in the Federal Register on December 15.
New Place of Service (POS) Code 27 - “Outreach Site/Street”
On December 14, CMS published Medicare Claims Processing Transmittal 12411, which rescinds and replaces Transmittal 12254, dated September 20, to add a new business requirement (13314.3) providing direction on how to treat claims submitted with POS 207. The original transmittal was published regarding the creation of the new POS code 27 for “Outreach Site/Street.”
Effective date: October 1, 2023
Implementation date: January 2, 2024
CMS Letter to Plans and Pharmacy Benefit Managers
On December 14, CMS released a Fact Sheet on its letter to pharmacy benefit managers (PBM) and Medicare Part D, Medicaid Managed Care, and private insurance plans sent on the same date. CMS wrote the Letter after hearing concerns that certain practices by these groups threaten the sustainability of many pharmacies, impede access to care, and increase burden on providers.
In the letter, CMS encouraged Part D plan sponsors and PBMs to make necessary cash flow arrangements with network pharmacies to prepare for the new pharmacy price concessions provision, which takes effect on January 1, 2024. CMS also touched on the inappropriate use of utilization management tools and reminded plans that it will be conducting robust oversight to ensure Medicare Advantage plans follow the coverage requirements and abide by the protections established via a final rule published earlier in 2023.
Toolkit to Help Decrease Improper Payments in Medicare Advantage Through the Identification of High-Risk Diagnosis Codes
On December 14, the OIG published a Toolkit intended to help Medicare Advantage (MA) organizations identify and evaluate high-risk diagnosis codes to ensure proper payments based on risk adjustment. The toolkit comes following months of OIG audits showing MA plans failed to identify diagnoses codes at high risk for being miscoded and then submitted those high-risk codes, which are used to help calculate risk-adjusted payments.
Updated OIG Work Plan
On December 15, the OIG updated its Work Plan with the following new items:
- Audit of Medicare Payments for Emergency Department Services Provided in Nonemergency Department Sites of Service
- Audits of Pharmacy Support for Prescription Drug Event Data
- Medicare Payments for Home Dialysis Services